Provider Demographics
NPI:1962413682
Name:KOTANSKY, AMY D (MS, RD, CDCES, LD)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:D
Last Name:KOTANSKY
Suffix:
Gender:F
Credentials:MS, RD, CDCES, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-3629
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5230 E STOP 11 RD STE 150
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6399
Practice Address - Country:US
Practice Address - Phone:317-865-5904
Practice Address - Fax:317-865-5321
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN711259133V00000X
IN37000390A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN37000390AOtherLICENSE